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A    N 

INAUGURAL   DISSERTATION 

O    N 

COMPRESSION  OF  THE  BRAIN  FROM 
CONCUSSION. 


SUBMITTED    TO    THE    PUBLIC    EXAMINATION 
OF       THE 

FACULTY     OF    PHYSIC, 

UNDER    THE    AUTHORITY    OF    THE 

TRUSTEES    OF    COLUMBIA    COLLEGE 

IN      THE 

STATE  OF  NEW-YORK: 
WILLIAM  SAMUEL  JOHNSON,  LL.D.  Prefident; 

FOR    THE    DEGREE    OF 

DOCTOR    OF    PHTSICi 

ON  THE  THIRTIETH  DAY  OF  APRIL,    I793. 


By    JOHN    B.    HICKS, 

Citizen  of  the  State  of  New- York. 

Experience  and  Obfervation,  the  Parents  of  the  Healing  Art. 

Lzdsan. 


NEW-YORK: 

Printed  by  T.  and   J.  Swordi,  Printers  to  the  Faculty  of   Phyfic  of 
Columbia  College,  No.  i-j,  William-Street. 

—•793  — 


• 


- 

Imprimatur. 


- 


fin 


Richard  Bay  ley, 


H5.SL 


5 


TO       THE 


MEDICAL    SOCIETY 


0    9       T    II    I 


STATE  OF  NEW-YORK: 


GENTLEMEN, 

PERMIT  me  to  addrefs  this 
INAUGURAL  ESSAT,  not  as  worthy  of  your 
fanclion,  but,  as  an  evidence  of  ejleem,  rejpecl,  and 
gratitude. 

From  your  much  obliged, 

Humble  Servant, 

The  AUTHOR; 


ISAAC  ROOSEVELT,  Prefident, 


THEOPHILACT  BACHE,  Vice-Prefident, 
JOHN  MURRAY,  Treafurer, 
JOHN  KEESE,  Secretary, 


HENRY  HAYDOCK, 
WILLIAM  EDGAR, 
SAMUEL  FRANKLIN, 
THOMAS  PEARSALL, 
JOHN  MURRAY,  Junior, 
GEORGE  BOWNE, 
LAWRENCE  EMBREE, 
JACOB  WATSON, 
SAMUEL  JONES, 
THOMAS  BUCHANAN, 
GERARD  WALTON, 
HUGH  GAINE, 
ALEXANDER  ROBERTSON, 
ROBERT  BOWNE, 
RICHARD  MORRIS, 
JOHN  LAWRENCE, 
ROBERT  R.  LIVINGSTON, 
JAMES  WATSON, 
CORNELIUS  RAY, 
MATTHEW  CLARKSON, 
SAMUEL  OSGOOD, 
MOSES  ROGERS, 


o 
o 
< 

M 
25 


GENTLEMEN, 

I  OUR  liberal  exertions  in  fupport  of  the  New- York  Hospital 
demand  my  approbation  at  a  citizen,  and  gratitude  as  a  child  of  the 
inftitution. 

Your  judicious  felecVion  of  medical  officers  not  only  effccluares 
the  public  bounty  to  thofe  viflims  of  difeafc  who  arc  objects  of  the  infti- 
tution. 


C     6     ) 


tutlon,  but  enables  the  patrons  of  the  healing  art  to  eftabliih  one  of 
the  firft  PRACTICAL  MEDICAL  SCHOOLS  on  the  Continent  of 
America. 

You  have  combined  in  the  fame  body,  a  fource  of  balm  to  the  afflicted, 
and  obfervation  for  the  advancement  of  the  moft  noble  of  fciences }  and 
thus  the  remoteft  parts  of  the  habitable  globe  will  participate  the  fruits 
of  your  benevolence. 

As  men  ftudious  to  promote  the  arts  and  fciences,  permit  me  to  fuggeft 
the  flourifliing  ftate  of  medical  education  in  this  city.  An  infti- 
tution  recently  adopted  by  Columbia  College,  nearly  allied  to,  and 
cheriflied  by  the  one  under  your  direction,  though  in  its  infancy,  fupport- 
ed  by  the  Pillars  of  Literature,  is  now  emerging  from  obfcurity,  and  will 
foon  mine  confpicuous  by  its  tendency  to  diffufe  useful  knowledge. 

How  pleafing  the  reflection,  that,  in  this  inftitution,  Columbia 
boafts  of  a  youth  of  genius  and  erudition,  unequalled  in  the  hiftory  of 
fcience.* 

May  Providence  continue  to  be  your  guide,  and  jrour  future  adml- 
niftration  be  fuch  as  to  merit  a  continuance  of  the  confidence  of  thofe 
whom  you  have  the  honour  to  reprefent. 

I  remain, 

With  much  efleem  and  refpett, 

Your  obliged, 

And  very  humble  Servant, 

The  AUTHOR; 

•Profeflbr  Mit chill. 


INTRODUCTION^ 


INTRODUCTION. 


Ti 


HE  Scnforium  Commune  has  attracted  the  atten- 
tion of  the  ablefl  Philofophers.  Its  phyjiology  has  eluded 
the  researches  of  ingenuity  and  induftry,  is  involved  in 
obfcurity,  and  hence  the  uncertainty  of  the  -pathology. 
We  have  to  lament  the  impojfibility  of  exploring  this  hid- 
den^ important,  and  inimitable  machine  of  infinite 
wisdom. 

Though  Surgery  has  rapidly  improved  for  a  few  years 
paft,  fill,  within  its  province  cxift  a  variety  of  difeafes  \ 
the  caufe,  nature,  and  cure  of  which  b affile  the  ingenui- 
ty of  Surgeons. 

Although  the  obfervations  which  I  now  fubmit  to 

public  fcrutiny  conflitute  my  Inaugural  Essay,  they 

were  not  compofed  merely  in  compliance  with  the  sta- 

7  utes  of  the  injlitution  under  whofe  fanttion  Ipublijh, 

but  from  a  full  conviction  of  their  -propriety  ;  for  though 

they  have  been  f ub jells  of  "inv  efl  igat  ion,  fine  e  Surgery  has 

been  cultivated  as  an  art,  we  are  inpoffeffion  of  nofatis- 

;  information  refpeSing  them. 

In 


C     8     ) 

In  profecuting  thefe  fubjefis,  an  inter efting  queftion 
offers  for  critical  examination -,  to  wit,  Are  the  difeafes 
known  infurgical  authors,  by  concuffion  and  comgreffion 
of  the  brain,  ejfentially  different  ? 

It  is  of  infinite  moment  in  practice  to  have  difeafes 
defined  with  accuracy  ;  for  though  modern  indufiry  has 
unburthened  Surgery  of  its  ancient  barbarity,  yet,  in 
-many  inftances,  we  are  under  the  difagreeable  neceffity  of 
obtaining  the  aid  of  painful  and  dangerous  operations ; 
and  hence  the  quefiion  fated  has  not  only  agitated  and 
perplexed  our  predeceffors,  but  the  ablefi  of  our  cotem- 
poraries  are  embarraffed,  and  have  fplit  on  this  ground. 

'Though  I  am  bold  to  relinquifh  the  beaten  tracl,  and 
controvert  the  theory  and pratlice  of  eminent  Surgeons, 
Iprefume  Ifhall  not  be  impeached  with  a  thirft  for  no- 
velty or  a  fpirit  of  controverfy.  If  I  have  advanced 
opinions  repugnant  to  eftablifhed  pratlice  and  great  au- 
thority, it  has  been  with  all  deference ;  from  a  convitHon 
of  their  propriety,  and  a  dejire  of  alleviating  the  cala- 
mities attendant  on  mortality. 

The  ignorant,  illiberal,  and  rafh  may  charge  me  with 
vain  per fumption;  but  the  wife,  candid,  and  deliberate 
will  applaud  my  independence. 

This  difparity  of  fentiment  is  not  peculiar  to  the 
healing  feience ;  but  we  are  not  equally  inter  eft  ed  and 

folicitous 


(      9      ) 

felicitous  for  the  purity  of  etich:  On-one  the  health  and 
lives  of  fociety  are  depending ;  the  others  are  more  the 
inquiries  of  curious  fpeculation  than  real  utility.  I  am 
an  advocate  for  lenity ;  but  when  I  contemplate  the 
nature  and  importance  of  the  fubjecl,  I  fpurn  at  the 
degeneracy  of  authors. 

'The  imperfecl  Jlate  of  this  part  of  fcience  has  arifen, 
in  fome  degree,  from  its  intricacy,  fervile  and  fuperfli- 
tious  veneration  for  authority ;  but  depravity  of  prin- 
ciple has  had  its  influence  •,  and  thus  the  light  of  truth 
has  been  obfcured  by  the  fhadow  of  the  imagination  •,  and 
to  ejiablifh  a  favourite  hypo  the/is,  fatls  have  been  coined^ 
and  wanton  cruelties  praclifed. 

We  are  rejlrainedby  humanity  >  and  prohibited  by  the 
laws  of  civil  fociety,  from  fporting  with  the  calamities 
and  lives  of  the  human  creation;  and  hence  the  propriety 
of  the  obligationmakzs  every  confideration  fubordinate 
to  the  welfare  of  th e  patient.  This,  however  humiliat- 
ing, and  painful  to  the  reflection,  is  too  frequently  aban- 
doned, and  inter ejl  and  ambition  predominate. 


JB  fciq 


A  N 


INAUGURAL  DISSERTATION,  &c. 


AT  is  almoft  unneceflary  to  remark,  that  this  dif- 
eafe  is  not  peculiar  to  any  feafon  or  climate  j  every 
part  of  the  habitable  globe,  both  fexes,  all  ages, 
and  every  variety  of  conftitution  are  the  objects  of 
its  vengeance.  A  complete  or  imperfect,  general 
or  partial  fufpcnfion  of  the  intellectual  operation, 
(cnfo,  and  voluntary  motion,  from  external  violence, 
with  the  continuance  of  refpiration  and  circulation, 
is  a  definition  fufficiently  clear  and  diftinct,  and 
plainly  enough  directing  the  indications  of  cure. 
But  in  obedience  to  cuftom,  and  further,  becaufe 
the  variety  marked  has  contributed  to  give  rife  to 
an  opinion  and  method  of  cure  which,  in  the  fub- 
fequent  part  of  this  efTay,  I  fliall  take  the  liberty  to 
controvert ;  I  proceed  to  mark,  with  precision,  the 
hiftory  in  particular. 

When 


(       ?*       ) 

When  the  violence  is  inflicted  the  following  is  the 
order  of  fymptoms. 

The  perfon  being  thrown  to  the  ground,  lies  ap- 
parently lifelefs  to  the  moft  accurate  examination. 
The  body,  face,  and  extremities  are  pale  and  cold ; 
the  eyes  lofe  their  fprightlinefs,  become  languid, 
and  afiume  a  deadly  appearance;  the  action  of  the 
heart  and  arteries,  and  the  function  of  refpiration,  are 
not  perceptible,  or  extremely  obfcure. 

In  this  fituation  he  continues  for  a  longer  or 
fhorter  time,  and  too  frequently  ends  his  exiftence : 
But  generally  the  involuntary  organs  recover  their 
fufpended  operations, 

The  breathing  is  deep,  fonorous,  laborious,  and 
flow  j  the  pulfe  irregular,  labouring,  and  opprefTed ; 
but,  fometimes  the  lungs  play  with  freedom  and 
eafe,  the  pulfe  is  free,  foft,  regular,  and  full ;  and, 
in  fhort,  the  ftate  of  the  vital  functions  correfponds 
to  that  of  Jleep, 

The  face  is  flufhed,  and  often  livid;  the  eyes  tur- 
gid, and  the  pupils  dilated ;  the  ftomach  is  affected 
with  naufea,  ficknefs,  and  vomiting  •,  inteftines  con- 
ftipated ;  and  thefe  fymptoms  are  frequently  accom- 
panied with  an  efFufion  of  blood  from  the  nofe, 
ears,  and  eyes. 

The 


(     *3     ) 

The  mufcles,  fubfervient  to  the  will,  are  vari- 
oufly  convulfed  -,  particularly  the  mufcles  of  one  fide 
are  violently  agitated  with  alternate  contractions  and 
relaxations,  while  thofe  of  the  oppofite  are  in  a  ftate 
of  perfect  paralyfis. 

Thefe  convulsions  are  often  extremely  obfeure, 
the  mufcles  being  affected  fimply  with  tremor,  efpe- 
cially  manifeft  in  the  distortion  of  the  features  of 
the  face. 

Thus  Situated  for  an  unlimited  time,  fufpended 
between  hope  and  defpair,  we  have  no  certainty  of 
approaching  death,  nor  evidence  to  warrant  a  con- 
jecture of  probable  recovery. 

At  length  the  fymptoms  are  mitigated;  the 
breathing  becomes  more  free  and  eafy ;  the  pulfe  re- 
gular, full,  more  quick  and  frequent ;  fenfibility  in 
fome  degree  returns  •,  he  is  reftlefs,  awake  to  active 
ftimuli,  is  fenfible  to  light ;  the  pupils  contract,  the 
eyes  exhibit  the  appearance  of  intoxication,  "  and 
he  'talks  incoherently." 

Thus,  gradually,  he  verges  from  the  jaws  of 
death,  again  to  exercife  the  functions  of  life,  and 
exhibit  health,  that  ineftimable  blefling.  Some 
degree  of  fatuity  continues  for  a  fhort  time;  and 
we  have  inftances  of  its  continuing  for  life,  accom- 
panied with  paralyfis. 

Our 


(      H     ) 

Our  efforts  to  obtain  this  falutary  termination  are" 
frequently  baffled ;  the  difeafe  purfues  a  different 
courfe-,  and  inftead  of  the  fymptoms  laffc  detailed, 
thofe  of  an  oppofite  complexion  take  place.  The 
breathing  is  Fmall,  flow,  and  very  obfcure;  the  pa- 
tient is  abfolutely  infenfible ;  his  pupils  remain  fixed 
and  dilated  when  expofed  to  the  ftrongefi  light ;  his 
face  and  extremities  are  pale  and  cold;  pulfe  fmall, 
very  flow,  weak,  and  intermittent;  the  urine  and 
fasces  pafs  involuntarily  -3  and  now  all  hopes  of  cure 
are  precluded,  and  death  is  at  hand.  At  length 
general  convulfions  fupervene  and  conclude  this 
painful  fcene. 


REMOTE    CAUSES. 


AUTHORS  have  generally  coniidered  the  divi- 
sion of  the  remote  caufes  into  occafional  and  predif- 
pofing,  as  fuperfiuous;  becaufe  (fay  they)  the  excit- 
ing never  requires  the  aid  of  predifpofition,  and  the 
difeafe  always  arifes  from  their  power  alone. 

That  this  is  generally  the  cafe  will  not  be  denied. 
But,  I  will  rifle  an  opinion,  that  inftances  have  oc- 
curred where  the  difeafe  has  been  avoided  from  the 
abfence  of  predifpofition,  and  in  every  occurrence 
is  aggravated  thereby. 

The 


(  m  ) 

The  neceflity  of  this  further  appears,  and  is  par- 
ticularly enforced  by  its  influence  in  determining  the 
prognosis,  and  directing  the  indications  of  cure. 


OCCASIONAL    CAUSE. 


COMMOTION  or  concuflion  of  the  brain. 


PREDISPOSITION. 


THIS  I  hold  to  confift  in  a  phlethorie  ftate  of  the 
fyftem  in  general,  and  of  the  head  in  particular. 
General  phlethora  may  arife  from  original  ftamina, 
a  liberal  ufe  of  animal  food  and  fpirituous  liquors; 
frequent  intoxication,  iedentary  life,  imbecility  in  the 
intellectual  operation,  interruption  or  fuppreflion  of 
the  fecretions,  fuppreflion  of  accuftomed  evacuations ; 
and,  we  are  told  that  frequent  bleeding  will  have  the 
fame  effect:. 

Phlethora  of  the  head,  in  particular,  may  depend 
on  original  conformation. 

A  large  head,  fliort  neck,  contracted  thorax,  and 
a  conftitutionally  lefs  capacity  of  the  lungs  in  pro- 
portion to  the  other  parts  of  the  body. 

Corpulent 


(     16    ) 

Corpulent  habit,  oflincation  of  the  valves  of  the 
heart,  and  debility  of  the  fame. 

Caufes  referred  to  the  lungs,  varioufly  interrupt- 
ing, impeding,  and  retarding  the  minor  circulation. 

Effufions  of  blood,  ferum  and  extrication  of  air 
in  the  cellular  fubftance  of  the  lungs. 

Hydrops  pericardii,  hydrothorax,  fpafms,  rigi- 
dity, and  tremors  j  tympanites,  aneurifms,  afcites, 
amputation \  youth,  old  age;  and,  in  fhort,  what- 
ever will  increafe  the  determination  to,  or  prevent 
the  return  of  blood  from  the  head,  will  produce 
a  phlethora  of  the  fame. 


PROXIMATE    CAUSE. 


THE  queftion  which  I  am  now  to  difcufs,  is  as 
interefting  to  the  Patient,  intricate  and  perplex- 
ing to  the  Practitioner,  as  any  within  the  jurifdiction 
of  Surgery.  .  . 

Surgeons  have  agreed  on  the  caufe,  nature,  and 
cure  of  compreflion  of  the  brain  from  external  vio- 
lence •,  imputing  the  difeafe  to  compremon,  depend- 
ing on  extravation,  congestion,  depreffion  of  bone, 
and  the  introduction  of  foreign  fubftances:     But 

the 


(     i7     ) 

the  fancy  of  modern  inquifitors  has  invented  a  new 
fpecies  of  difeafe,  entitled  Concuflion  of  the  Brain ; 
though  of  a  nature  diametrically  opposite,  in  the 
character  fo  nearly  allied  to  compreflion,  that  the 
diftinction  would  elude  the  penetration  of  a  Newton* 

With  all  deference  to  fuch  authorities,  I  believe 
the  fame  to  have  no  exiftence  in  nature,  and  to  be 
a  phantom  of  the  imagination  only. 

This  diftinction  was  firft  fuggefted  by  the  French,* 
who  are  unbounded  in  ambition,  enthufiafts  in  no- 
velty, happy  at  invention,  and  fond  of  the  marvel- 
lous. 

Like  contagion  it  has  diffufed  its  noxious  in- 
fluence, aflimilated  the  Surgeons  of  the  adjacent  and 
remoter!:  countries ;  and  to  this  caufe  too  many  owe 
their  diflblution. 

Authors  of  a  more  recent  date,  unfatisfied  with 
the  obfervations  of  their  predeceflbrs,  have  refined 
on  refinement-,  the  former  having  denied  the  exift- 
ence of  compreflion  in  concuflion,  to  which  the  latter 
have  added  debility  as  the  proximate  caufe,  and 
attributed  to  concuflion  a  direct  fedative  operation, 
analogous  to  contagion,  cold,  fear,  and  other  known 
fedative^.  \     What  a  ftrctch  of  the  imagination ! 

C  I  have 

*  Sharp'i  Ciiiical  Inquiry. 
-)   1541';  SyfUm  of  Suigery, 


(     i«     ) 

f  have  attentively  weighed,  and  revolved  in  my 
mind,  in  the  moil  favourable  point  of  view,  the  ar- 
guments urged  in  iupport  of  concuffion  independent 
of  compreffion,  and  I  am  forry  to  fay,  I  have  not 
been  able  to  difcover  a  rational  foundation  •,  and  no 
doubt  exifts  with  me  as  to  the  fallacy  of  their  ob- 
fervations, 

Upon  the  whole,  I  prefume  I  fhall  clearly  main- 
tain, that  the  variety  of  the  phaenomena  marked  in 
the  hiftory  of  compreffion,  and  other  circumftances, 
on  which  the  doctrine  of  concuffion  has  been  found- 
ed, may  be  referred  to  a  difference  in  the  predifpofi- 
tion,  &c.  which  gives  no  effential  difference,  implies 
an  analogous  operation  in  the  occasional  caufe,  marks 
a  variety  only,  and  mews  the  deception  of  experi- 
ence. 

Though  I  have  rejected  the  idea  of  excluding 
compreffion  in  what  authors  denominate  concuffion, 
I  admit  that  debility  is  induced,  is  to  be  fought 
for  to  explain  many  phenomena,  and  is  of  infinite 
moment  in  the  method  of  cure. 

This  debility  I  hold  to  be  indirect,  the  refult  of 
exceffive  ftimulus,  and  not  the  immediate  effect  of 
direct  fedative  powers. 

From 


(     i9     ) 

From  this  consideration  only  we  can  explain  the 
inftantaneous  fufpenfion  of  life,  and  immediate  re- 
ftoration  of  the  fame,  when  the  brain  is  fubjected 
to  violent  concufliorj. 

That  debility,  and  not  compreflion,  is  the  caufe 
of  the  phasnomena  in  this  inftance,  is  obvious  from 
the  following  reflections. 

What  reafon  can  be  given  why  the  functions  of 
life,  after  a  complete  fufpenfion,  inftantly  return  to 
exercife  with  their  ufual  energy  ? 

Abforption  is  a  tedious,  laborious  procefs,  and 
no  one  acquainted  with  the  laws  of  the  animal  ceco- 
iiomy  can  conceive  extravafation  and  abforption  in 
the  inftance  mentioned  ;  and  it  is  equally  improbable 
that  congeftion  exifted. 

All  caufes,  fo  far  as  they  have  a  mechanical  opera- 
tion, are,  to  the  human  body,  direct  ftimulants. 
By  comparing  the  phasnomena  of  concufllon  with 
the  morbid  effects  of  electricity,  joy,  anger  and 
pain,  the  moft  perfect  analogy  muft  ftrike  the  un- 
prejudiced and  enlightened  mind. 

As  the  phasnomena  of  concufllon  have  the  ftricteft 
refcmblance  to  thofe  of  electricity,  &c.  it  is  unphi- 

iofophic;i! 


(       20      } 

lofophical  to  fay,  that  the  fame  effects  refult  from 
oppofite  caufes.* 

Haying  refuted  the  idea  of  direct,  and  eftablifhed, 
upon  invulnerable  ground,  the  exiftence  of  indirect 
debility,  it  remains  to  mew  the  exiftence  of  com- 
preffion  in  concuffion, 

This  I  conceive  a  difficult  tafk,  more  fuited  to  age, 
experience  and  obfervation,  than  calculated  as  an 
exercife  for  a  youth  yet  an  infant  in  his  profeflion. 

Necellity  needs  no  apology,  and  I  afiume  the  ar- 
duous undertaking  with  that  diffidence  becoming  my 
period  of  life. 

I  have  already  maintained  the  exiftence  of  debility 
refulting  from  concuflion;  it  may  feem  paradoxical 
now  to  urge  the  neceflity  of  compreflion, 

I  wiih  to  be  clearly  comprehended.  The  opinion 
I  have  already  advanced  has  a  relation  to  circum- 
ftances,  feldom  the  objects  of  furgical  obfervation. 

No  one  is  ignorant,  that  inftances  daily  occur, 
where  life  is  fufpended  by  falling  from  a  height  on  the 
feet,  head,  or  other  parts ;  and  on  the  moft  accu- 
rate examination,  we  have  no  evidence  of  folution 
of  continuity,  conturlon,  extrayafation,  or  congeftion. 

We 

*  *.*.  Identity  of  effefl:  Implies  identity  of  caufe." 


(  %%  ) 

We  have  a  more  familiar  example  of  this  in  the 
impious  and  fhameful  practice  of  boxing.  We  have  all , 
witneffed,  and  many  have  experienced  what  pugilifts 
confider  as  an  invariable  rule,  that  a  blow  under  the 
ear,  between  the  maftoid  procefs  of  the  temporal 
bone  and  angle  of  the  jaw,  thrown  the  victim  to  the 
ground,  where  he  lies  apparently  inanimate-,  but  in  a 
few  moments  he  is  revived,  renews  the  conteft,  and 
engages  his  antagonift  with  redoubled  energy. 

This  (late  of  concumon  is  not  what  Surgeons  are 
contending  about.  When  the  intellectual  faculties, 
fenfe  and  voluntary  motion  are  no  more,  and  the 
vital  functions  continue  to  difplay  themfelves ;  when 
thefe  exift  to  a  considerable  degree,  and  are  of  fome 
duration,  they  conftitute  what  is  to  many  fimple  con- 
cuflion,  and  to  others  complete  compreffion. 

I  hold  it  as  a  principle  in  phyfiology,  that  a  free 
and  uninterrupted  ftate  of  the  nervous  power,  (what- 
ever that  may  be,)  is  necefTary  to  the  exigence  and 
exercife  of  the  intellectual  faculties,  fenfe  and  volun- 
tary motion. 

It  is  equally  true,  that  the  animal  functions  may 
be  fufpended,  and  the  vital  continue  in  action.  It 
appears,  therefore,  that  a  caufe  capable  of  effecting 
the  firft,  may  be  inadequate  to  the  fecond;  and  that 
in  the  difeafe  now  under  confidcration,  though  an 

injur/ 


(       22       ) 

injury  of  iome  kind  has  arretted  the  animal,  the  vital 
organs  are  fupported  by  that  ftate  of  the  fenforium,  or 
nervous  energy,  which,  though  inefficient  for  the 
former,  is  equal  to  the  latter.  I  am  aware  of  the 
objection,  that  the  phenomena  which  I  have  juft  laid 
down  as  depending  on  compreffion,  are  frequently 
the  effects  of  a  ftate  of  the  nervous  Jyjfem,  in  which 
we  have^  (fay  they)  no  caufe  to  fuipeet  compreffion. 

The  firft  of  which  is  Jleep. 

That  this  ftate  is  not  produced  by  extravafation  is 
obvious ;  but  to  me  it  is  equally  probable,  that,  though 
compreffion  is  not  the  firft  caufe  of  fleep,  it  completes 
and  preferves  that  ftate,  and  without  which  it  would 
never  take  place. 

I  am  perftiaded  of  the  truth  of  this  from  a  variety 
of  confederations. 

The  mechanifm  of  the  brain,  which  is  calculated 
to  retard  and  accumulate  the  blood  in  this  organ, 
while  no  other  ufe,  equally  probable,  can  be  affigned, 
(except  giving  a  certain  degree  of  energy  to  the  ner- 
vous fyft  em)*  is  fufficient  evidence,  in  a  cafe  intricate 
as  the  prefent,  to  warrant  the  aflertion.-f- 

"  Befide 

*  On  one,  the  mod  fi-nple  principle,  nature  accomplices  two  of  the 
moft  important    ends    in   the    animal    ceconomy,    excitement    and 

COLLAPSE. 

•J-  This  explanation  of  the  sensorium  does  away  what  has  hither- 
to been  considered  a  desideratum  in  physiology;  to  wit,  a  rcafon 


r 


( 23 ) 

c*  Bdide  the  caufes  now  mentioned  occalioning 
apoplexy  by  compreflion,  I  alledge  there  are  other 
caufes  producing  the  fame  difeafe,  by  directly  deflroy- 
ing  the  mobility  of  the  nervous  energy.  Such 
caufes  feem  to  be  mephitic  air  arifing  from  ferment- 
ing 

why  a  greater  quantity  of  blood  is  distributed  to  this  organ  than  is  necefTary 
for  its  nourishment.  On  this  has  been  built  the  favourite  hypothecs  of 
the  nervous  fluid.  I  f  we  re  af on  from  analogy,  (fay  they,)  the  brain 
is  a  gland,  deftined  for  the  fecretion  of  a  peculiar  fluid ;  it  being  a  fadt, 
that,  whenever  a  greater  quantity  of  blood  is  fent  to  any  organ  than  is  re- 
quired for  its  fupport,  it  is  intended  for  fecerning  from  the  circulating 
mafs  a  certain  fomething  sui  generis.  To  this  rule  there  are  obje&ions; 
thespLElN,  ^■■■tiiid  ca?vl.£  sekales;  in  none  of  which 
have  we  any  evidence  of  their  glandular  ftruc"lure,  no  excretory  duct 
hiving  been  difcovered  5  nay,  I  may  with  propriety  fay  never  will. 

The  explanation  given  is  confiftent  with  the  more  remote  caufes  of  fleep. 
Exercife  of  the  various  functions  of  the  body,  by  exhaufting  the  energy 
of  the  fyftem,  favours  congeftion  in  the  vefTels  of  the  brain  ;  for,  as  the 
velfels  of  this  part  forward  their  blcod  by  their  own  energy  and  the  vifa- 
tergo  ;  fo,  in  cafes  of  general  debility,  parts  thus  fituated,  are  molt  rea- 
dily furcharged ;  and  hence  the  head,  thoracic,  and  abdominal 
viscera  are  moll;  frequently  affeifted  with  congeftion.  In  this  way  Na- 
ture compels  the  moft  obuinate  to  yield,  and  enforces  recreation.  We 
have  a  further  illustration  of  this  from  the  fomniferous  effefts  of  cold. 
We  all  know,  that  when  expofed  to  a  degree  of  extreme  cold,  we  become 
drowfy  ;  and,  fcnlible  of  the  impending  evil,  in  vain  we  refill,  fleep  ap- 
proaches, and,  if  the  caufe  continues,  we  expire  without  a  fenfe  of  pain, 
anxiety,  or  regret.  I  conceive  that  cold  produces  thefe  effedts,  by  dimi- 
nishing the  energy  of  the  fyitem  ;  the  heart,  unable  to  exert  its  ufual  force, 
propyls  the  blood  with  difficulty  in  the  extreme  parts,  and,  therefore,  it 
accumulates  internally,  but  more  particularly  in  the  vefTels  of  the  brain, 
for  the  reafoni  before  given.  ^ 

A  difficulty  here  arifej — if  congestion  is  the  caufe  of  deep,  what  folu- 
tion  will  be  given,  why  a  perfon  can  be  inflantly  awoke?  Compreffion 
from  eitrarafation,  and  that  from  congestion  in  the  vefTels,  are  different 
with  refpeel  to  duration.  In  the  firft,  compreffion  can  only  be  relieved  by 
*bf  .rpi.ion,  wlnlr,  in  the  latter,  a  relloration  of  adtion  alone  is  all  that  ii 
icqijifite  j  therefore,  on  the  caufe  of  excitement  being  given,  he  is  a  woke ; 


(     H     ) 

frig  liquors,  and  from  many  other  fources ;  the  fumes 
arifing  from  burning  charcoal  ;  the  fumes  of  mercu* 
ry,  of  Jead,  and  fome  other  metallic  fubftancesj 
opium,  alcohal,  and  many  other  narcotic  poifons  i 
To  which  I  would  add  the  power  of  cold,  of  con- 
cuflion,  of  electricity,  and  of  certain  paftions  of  the 
mind. 

"  None  of  thefe  poifons,  or  noxious  powers,  feem 
to  kill  by  acting  on  the  organs  of  refpiration,  or 
fanguiferous  fyftemj  and  I  believe  their  immediate 
and  direct  operation  to  be  on  tWiwUPoiis  power, 
deftroying  its  mobility  •,  becaufe  thefe  poifons  fhew 
their  power  in  deftroying  the  irritability  of  mufcles, 
and  of  the  nerves  connected  with  them,  when  both 
thefe  are  entirely  feparated  from  the  reft  of  the  body. 

"  With  refpect,  however,  to  the  circumftances 
which  may  appear  on  diflection  of  perfons  dead  of 

apoplexy, 

but  even  this  is  not  immediately,  for  frequently  he  continues  in  a  ftate  of 
femi-watching  for  fome  time ;  and  when  he  is  revived,  on  withdrawing  the 
caufe,  he  (inks  in  the  fame  ftate ;  and  if  he  does  not,  it  is  only  after 
fome  time  that  the  watching  ftate  is  completed. 

I  conceive,  however,  that  the  caufes  principally  to  be  noticed  in  explain- 
ing the  phaenomenon  of  fleep,  j£a  peculiar  organization  and  habit.  We 
have  a  beauf  iful  illuftration  of  this  in  the  organ  of  voice  :  here  the  moft 
^ftonifhing  phenomena  in  the  animal  machine  depend  on  peculiarity  of 
organization,  and  a  facility  of  action  in  the  mufcles  fubfervient,  acquired 
by  repetition  :  fo  the  fame  caufes  referred  to  the  sensorium,  may  produce 
congestion  and  inanition  not  to  be  expected  a  priori ;  and  hence  the  caufe 
of  children  fleeping  ia  much  more  than  adults,  and  as  they  advance.  t» 
puberty  of  its  gradually  dimlnilhin  j. 


(    H    7 

apoplexy,  there  may  be  fome  fallacy  in  judging  from 
thofe  of  the  caufe  of  the  difeafe.  Whatever  takes  off, 
or  diminishes  the  mobility  of  the  nervous  power,  may 
very  much  retard  the  motion  of  the  blood  in  the  vef- 
fels  of  the  brain,  and  perhaps  to  a  degree  of  increasing 
exhalation,  or  even  of  occasioning  rupture  and  effu- 
fion  i  fo  that,  in  fuch  cafes,  the  marks  of  compreflion 
may  appear  upon  diflection,  though  the  difeafe  had. 
truly  depended  on  caufes  destroying  the  mobility  of 
the  nervous  power.  This  feems  to  be  illuftrated 
and  confirmedhfrom  what  occurs  in  many  cafes  of 
epilepfy :  in  fome  of  thefe,  after  a  repetition  of  fits, 
recovered  from  in  the  ufual  manner,  a  fatuity  is  in- 
duced, which  commonly  depends  upon  a  watery  in- 
undation of  the  brain  i  and  in  other  cafes  of  epilepfy, 
when  fits  have  been  often  repeated  without  any  per- 
manent confequences,  there  happens  at  length  a  fatal 
paroxifm ;  and,  upon  diSTedion,  it  appears  that  an 
effufion  of  blood  had  happened.  This,  I  think,  is 
to  be  considered  as  a  caufe  of  death,  not  a  caufe  of 
the  difeafe-,  for,  in  fuch  cafes,  the  difeafe  had  dimi- 
nifhed  the  action  of  the  veffels  of  the  brain,  and 
thereby  given  occafion  to  a  Stagnation,  which  pro- 
duced the  appearances  mentioned.  And,  I  appre- 
hend the  fame  reafoning  will  apply  to  the  retro- 
cedent  gout,  which,  by  deftroying  the  energy  of  the 
brain,  may  occafion  fuch  a  ftagnation  as  will  produce 
D  rupture, 


(       26         ) 

rupture,  effufion,  and  death ;  and  in  fuch  cafes  the 
appearances  might  lead  us  to  think  that  the  apoplexy 
had  depended  entirely  on  compreflion." 

In  thefe  quotations  we  have  the  authority  of  Doc- 
tor Cullen,  together  with  extreme  plausibility,  to 
fhew,  that  concuffion,  though  it  produces  debility  in 
the  nervous  fyftem,  is  attended  with  compreflion. 

This  the  Doctor  will  not  admit  as  a  caufe  of  the 
cfifeafe,  but  as  an  effect  of  death,  for,  what  reafon  I 
am  at  a  lofs  to  fay. 

1  might  with  equal  propriety  contend,  that  ex- 
travafation or  depreffion  of  bone  from  external  vio- 
lence, were  not  the  caufes  of  an  apoplexy  in  fuch  in* 
fiances,  becaufe  they  were  occafioned  by  external 
violence  -,  and,  therefore,  the  force  applied  is  the 
caufe,  and  extravafation  or  depreffion  of  bone,  the 
effect  of  death :  For  what  is  the  difference,  whether 
the  effufion  or  extravafation  is  the  effect  of  rupture 
by  violence,  or  rupture  and  effufion  from  a  want  of 
energy  in  the  vefiels  ? 

In  the  former  the  apoplexy  evidently  depends  up- 
on extravafation  and  deprefled  bone ;  and  it  is  equally 
true,  that,  in  the  latter,  though  debility  of  the  ner- 
vous energy  occafioned  the  rupture  and  effufion,  de- 
bility independent  of  that  would  not  produce  the 

apoplectic 


(       27       ) 

apoplectic  ftate;  for,  if  it  Would,  a  reftoration  of 
energy  would  be  the  cure :  this  is  contrary  to  fact, 
and  therefore  debility  is  the  remote,  and  compreffion 
thQ  proximate  caufe,  and  not  the  effect  of  death. 

The  fact  which  I  am  now  to  lay  down  as  invariably 
the  cafe  in  every  inftance,  and  for  the  truth  of  which  I 
appeal  to  every  Practitioner  experienced  in  Surgery, 
that  when  concuffion  of  the  brain  is  of  duration 
fufficient  to  fall  under  the  obfervation  of  Surgeons 
and  Phyficians,  it  will  be  found,  that  the  animal  and 
v\tal  functions  were  extinguifhed  at  the  inftant  of 
concuffion,  and  that  this  is  momentary :  For  though 
the  animal  functions  continue  in  a  ftate  of  fufpenfion, 
the  vital  renew  their  action ;  and  in  this  ftate  the 
perfon  remains  for  an  unlimited  time^ 

If  concuffion,  independent  of  compreffion,  flip- 
ports  the  difeafe  under  the  circumftances  I  have  men- 
tioned, I  a(k  a  reafon  why  the  animal  as  well  as  the 
vital  functions  were  not  reftored. 

A  reply  to  this  queftlon  I  conceive  will  be  diffi- 
cult, and  a  rational  folution  only  can  be  given  on  the 
principle  of  compreffion. 

That  debility  alone  docs  not  exhibit  the  phenome- 
na, I  conclude  from  hence,  that  if  it  did,  there  would 

be 


(        28       ) 

be  no  paufe  at  the  vital,  and  the  animal  functions 
would  be  reftored  in  the  fame  progreflion :  This, 
however,  is  otherwife  ;  for  the  animal  functions  do 
not  proceed  to  a  reftoration  of  action  in  the  fame 
progreflion,  but  remain  in  a  ftate  of  abolition  for  a 
confiderable  time,  and  at  length  frequently  end  in. 
death. 

This  is  a  ftubborn  objection  to  the  dodrine  of 
concuflion  independent  of  compreflion,  and  we  muft 
purfue  fome  other  courfe  to  arrive  at  the  truth.  J 
would  attempt  it  in  this  way  :  Violence  of  excitement 
from  concuflion  terminates  in  &  ftate  of  collapfe 
analogous  to  fyncope  from  joy. 

I  confefs,  that,  in  this  ftate,  the  neceflity  of  com- 
preflion does  not  appear ;  I  prefume  at  the  fame 
time,  that  extravafation  accompanies  the  excitement, 
or,  that  congeftion  in  the  yeflels  takes  place  at  the 
time  of  collapfe. 

If  fyncope  from  joy  does  not  terminate  in  a  ftate 
of  irrecoverable  collapfe,  it  in  a  few  moments  difap- 
pears,  and  excitement  returns;  fo,  in  cafe  of  col- 
lapfe from  concuflion,  the  fame  takes  place,  except 
with  this  difference,  that  in  fyncope  excitement  is 
reftored  to  the  whole  fyftem  •,  whereas,  in  concuflion, 
to  the  vital  funffiqns  only. 

The 


(     29     ) 
The  following  is  the  reafon. 

I  have  ftated  it  as  a  principle  in  phyjiology,  that 
a  caufe,  capable  of  fufpending  the  animal,  may  be 
inadequate  to  produce  the  fame  effect  on  the  vital 
organs :  Now,  I  conceive,  that  in  the  inftance  of  con- 
cuflion,  life  is  fufpended  from  collapfe  only,  and  the 
excitement  is  reftored  to  the  vital  functions  -,  becaufe 
extravafation  or  congestion  in  the  veflels  producing 
compreflion,  exifts  at  the  fame  time  j  and  though 
inadequate  to  any  manifeft  injury  on  the  vital,  is  com- 
petent to  a  lofs  of  the  animal  f Millions. 

Bell,  in  his  Syftem  of  Surgery,  fays,  "  So  far  as 
my  obfervation  goes,  the  mod  material  difference 
which  occurs  between  the  fymptoms  produced  by 
theft  two  caufes,  concuflion  and  compreflion,  is  met 
with  in  the  pulfe  and  in  the  breathing. 

"  In  a  compreffed  ftate  of  the  brain,  the  breathing 
is  commonly  deep  and  oppreffed,  fimilar  to  what 
moft  frequently  takes  place  in  apoplexy-,  whereas, 
ill  patients  labouring  under  commotion  or  concuflion, 
the  breathing  is  in  general  free  and  eafy,  and  the 
patient  lies  as  if  he  was  in  a  found  and  natural  flecp. 
The  pulfe  is  commonly  foft  and  equal,  and  not 
irregular  and  flow,  as  it  ufually  is  found  to  be  when 
the  brain  is  compreffed. 

"In 


(     3°     ) 

"  In  cafe  of  comprefled  brain  too,  although  little 
or  no  relief  may  be  obtained  from  blood-letting, 
yet  no  harm  is  obferved  to  accrue  from  it;  for  in 
fuch  circumftances  it  may  be  prefcribed  in  moderate 
quantities,  without  reducing  either  the  frequency  or 
ftrength  of  the  pulfe ;  whereas,  in  real  concuflion  of 
the  brain,  the  pulfe,  as  we  have  already  remarked, 
will  frequently  fink,  and  become  more  feeble  on  the 
difcharge  of  only  eight  or  ten  ounces  of  blood." 

Thefe  obfervations,  on  the  circumftances  of  the 
two  difeafes,  may  induce  an  inattentive  obferver  m 
adopt  the  diftinction  \  but,  I  apprehend  I  mail  be 
able  to  account  for  the  variety  quoted,  and  admit 
the  exiftence  of  compreflion. 

There  is  a  ftate  of  the  arterial  fyftem  which  pa- 
thologists have  named  phlethora  ad  vires ;  and  we  all 
know  the  exiftence  of  inanition  produces  an  oppo- 
site ftate-,  the  compreflion  being  given,  thefe  two 
ftates  of  the  fanguiferous  fyftem  will  give  the  variety : 
For  inftance,  if  a  phlethora  ad  vires  fhould  exift;  in 
one,  and  inanition  in  another,  the  firft  will  prefent 
the  fymptoms  of  compreflion;  the  fecond  will  exhibit 
the  phenomena  of  concuflion. — In  fupport  of  this 
an  explanation  may  be  required. 

The 


(     3*     ) 

The  pulfe  in  phlethora  ad  vires  is  irregular,  flow 
and  opprefled,  and  correfponds  to  that  of  compref- 
fion.  This  does  not  arife  from  a  want  of  energy  in 
the  nervous  fyfiem,  but  from  the  equilibrium  be- 
tween the  arteries  and  their  contents  being  deftroyed, 
from  the  predominancy  of  the  latter. 

The  fame  consideration  accounts  for  the  deep  and 
oppreffed  breathing ;  for,  as  this  organ  is  a  mixture 
of  voluntary  and  involuntary,  and  as  the  animal 
functions  are  fufpended,  the  mufcles,  fubfervient  to 
the  organ  of  refpiration,  refufe  their  afliftance ; 
and  hence  the  ftate  of  refpiration  in  compreffion* 
Further,  the  blood  is  accumulated  in  the  right  au- 
ricle and  ventricle  of  the  heart,  from  the  flownefs  of 
refpiration,  the  diminifhed  energy  of  the  heart  and 
phlethora  ;  and,  therefore,  a  deep  infpiration  is  ne- 
cefTary  to  the  tranfmimon  of  the  accumulated  blood. 

The  breathing  is  free  and  eafy,  the  pulfe  foft  and 
equal  in  concumon,  and  anfwers  to  that  of  fleep. 

I  have  no  doubt  but  Practitioners  have  been  de- 
ceived by  thofe  circumftances  of  the  breathing  and 
pulfe,  bccaufe  I  mall  now  prove  them  to  depend  up- 
on com  preflion. 

The  cavity  of  the  crarium  being  given,  and  always 
the  fame,  at  different  times  it  will  be  more  or  lefs 

completely 


(       32       J 

completely  filled,  according  to  the  ftate  of  the  vejfels  of 
the  brain.  If  two  perfons  of  unequal  ftates  of  pble- 
thora  fhould  have  accumulated  in  the  fcull  the  fame 
quantity  of  matter,  one  may  receive  comprefnon 
equal  to  a  complete  ftate  of  apoplexy ',  and  the  other 
mall  receive  no  injury,  or  if  he  does  it  will  be  in  a 
lefs  degree ;  for  the  accumulation  being  given,  the 
comprefnon  will  be  in  proportion  to  the  phlethoric 
fiate  of  the  brain. 

A  more  lnconfiderable  accumulation  and  ftate  of 
inanition  of  the  vejfels,  will  explain  why  a  foft,  equal 
pulfe,  and  a  free,  eafy  refpiration  takes  place  in  this 
Inftance  and  not  in  the  other.  As  refpiration  is  iii 
fome  degree  under  the  influence  of  the  will,  it  Will  be 
impaired  in  proportion  to  the  lofs  of  the  fame ;  and 
as  the  degree  of  refpiration  required  will  be  in  pro- 
portion to  the  quantity  of  blood  to  be  circulated  by 
the  lungs,  we  have  <  a  reafon,  without  the  neceffity  of  a 
comment,  why  the  ftate  of  the  vital  organs  corref- 
ponds  to  a  ftate  of  Jleep,  having  previoufly  fhewn 
this  phenomenon  to  depend  on  comprefnon. 

DifTeclion,  fb  frequently  the  refource  of  Surgeons, 
Is  often  fallacious. 

We  have  it  roundly  afterted  in  books  of  furgery, 
that  after  the  moft  attentive  examination  of  many 

who 


(     33    ') 

who  died  of  concuffion,  they  were  not  able  to  dif- 
cover  the  leaft  veftige  of  compreffion. 

It  would  be  illiberal  to  charge  the  authors  of 
fuch  direction  with  wilful  mifreprefentations  of  the 
refult  of  their  inquiries;  but,  I  may  with  the 
ftricteft  propriety  obferve,  that  it.  did  exift  in  every 
fuch  inftance,  though  it  eluded  the  eyes  of  thofe 
blinded  by  prejudice. 

I  mail  anticipate  the  reply  to  this  obfervation,  that 
the  fame  refult  has  attended  the  purfuits  of  the 
warmeft  advocates  for  compreffion:  I  admit  the 
fact,  but  deny  the  force  of  this  as  an  objection. 

Compreffion  from  external  violence  has  hitherto 
been  confidered  as  produced  by  extravafation,  de- 
preffied  bone,  and  the  introduction  of  foreign  fub- 
ftances :  was  this  a  fact,  I  mould  be  in  fome  meafure 
defeated  by  the  energy  of  their  difTection3:  but, 
compreffion  from  concuffion  is  frequently  the  effect 
of  congestion  in  the  veffels  of  the  brain. 

Again,  though  extravafation  mould  exift,  in  thofe 
inftanccs  in  which  we  are  told  diffiection  has  dif- 
proved,  I  fay,  I  can  eafily  conceive,  that  the  moft 
accurate  and  liberal  diflcctors  may  have  been  de- 
ceived j  for  the  extravafated  matter  neceflary  to 
produce  this  effect   under  particular  circumftances, 

E  is 


(     34     ) 

is  tod  inconfiderable  to  ftrike  the  fenfes,  unlefs  the 
fame  be  fubjecled  to  the  mod:  fufpicious  examination. 

The  circumftance  I  have  juft  mentioned  is  not 
the  only  caufe  of  error  in  fuch  cafes ;  for  the  feat 
of  compreflion  has  generally  been  considered  as 
exifting  between  the  duramater  and  crarium,  the 
former  and  pia  mater,  or  the  latter  and  brain:  I 
conceive,  however,  that  extravafation  may  with 
equal  facility  take  place  in  the  fubftance  of  the 
brain,  or  fome  other  internal  part,  as  thofe  for- 
merly  mentioned.* 

Further*  extravafation  of  blood  is  not  a  neceflary 
confequence  of  rupture  of  the  veflels  of  the  brain  from 
concuflion ;  for  ferum  only  may  be,  and  frequently 
is  efFufed,  and  proves  a  caufe  of  compreflion. 

Now,  from  the  facts  which  I  have  juft  mention- 
ed ;  to  wit,  a  falfe  idea  of  the  feat  of  compreflion, 
a  partial  knowledge  of  the  caufes,  and  from  the 
inconfiderable  quantity  of  extravafated  matter  ne- 
ceflary to  produce  this  effecT:,  it  is  probable,  that 
diflection  has  done  little  more  than  nourifti  an  ab- 
furd  preconceived  opinion. 

As  congeftion  in  the  veflels  of  the  brain  is  the 
caufe  in  many  inftances  of  compreflion  from  concuf- 

fion, 

*  Pott'e  Surgery. 


(     35     ) 

fion,  the  reafon  is  obvious,  why  difTectors  have 
been  fo  often  baffled  in  difcovering  a  caufe  of  com- 
preflion. 

If  they  had  no  fufpicion  of  the  exigence  of  fuch 
a  caufe,  is  it  probable  that  if  it  did  exift,  it  would 
fall  under  their  obfervation  ?  I  anfwer  no  j  becaufe 
the  nature  of  congeftion  may  be,  and  generally  is 
fuch,  as  to  render  its  exiftence  ambiguous  to  thofe 
who  contend  for  its  prefence. 

The  celebrated  Bromfield  and  others  found,  from 
long  extennve  experience  and  much  obfervation, 
that  the  afthenic  plan  was  too  rigidly  obfervedj  and 
therefore,  without  a  knowledge  of  the  caufe  of  the 
inefficacy  of  their  practice,  empirically  ventured  to 
relinquifh  the  fame,  and  fubmit  to  fudorifes  in  fuch 
cafes.* 

I  have  no  doubt  that  the  indifcriminate  practice  of 
venefetlion'm  concuflion  is.  often  injurious ;  and  lam 
equally  certain,  that  fudorifies,  cathartics,  and  every 
other  part  of  the  ajlhenic  plan,  are  no  lefs  ambiguous 
under  particular  circumftances. 

I  am  led  to  believe,  both  from  theory  and  practice, 
that  the  fatality  of  this  difeafe  is  owing  to  the  pre- 
judice in  favour  of  fyftcm,  whereby,  practicing  from 
general  indications,  many  and  infuperable  errors  are 

committed. 

If 

*   Bomfield's  Surgery. 


C    36    ) 

If  the  mortality  of  this  difeafe  has  abated  fince 
Surgeons  and  Phyficians  have  fufpe&ed  the  propri- 
ety of  bleeding  in  every  inftance,  and  all  ftages  of 
the  difeafe,  we  have  reafon  to  conclude,  that,  if  for 
the  afihenic  they  had  fubmitted  the  Jlbenic,  the  pro- 
portion of  deaths  in  fuch  inftances  would  have  much 
diminished. 

I  am  at  a'lofs  to  fay,  why  the  author  of  the  pre- 
fent  Syftem  of  Surgery  has  advanced  the  experience 
and  obfervations  of  Bromfield,  in  fupport  of  his  ri- 
diculous hypothecs  on  the  proximate  caufe  of  con- 
cufTion.*  I  admit  that  it  is  evidence  of  the  exist- 
ence of  debility  -,  but  this  I  mall  fhew  is  not  a  caufe, 
but  a  necefTary  confequence  of  that  fliate  of  the  brain. 

The  exercife  of  the  intellectual  faculties^  fenfe-f 
voluntary  motion  and  refpiration,  are  direct  ftimulants 
to  the  fyftem,  and  th,e  only  caufe  and  fupport  of  its 

activity, 

It  is  now  a  notorious  fact,  that  refpiration  is  a 
procefs  analogous  to  combuftion ;  and  that  the  of- 
fice of  the  minor  circulation  is  to  impregnate  the  blood 
with  wh~t,  in  the  new  nomenclature  of  the  French 
chemifts,  is  known  by  oxigene,  and  to  prove  the 
fource  of  animal  heat. 

It 

f  Bell's  Syftem  of  Surgery, 


(     37     ) 

It  is  equally  weil  eftablifhed,  that  the  exigence 
and  exercife  of  this  fun ^i on  is  efiential  to  animal  life: 
it  appears  further,  that  the  prefence  of  oxigene  is 
necefTary  to  the  action  of  the  heart  and  arteries,  it  be- 
ing the  natural  and  only  famulus  capable  of  fupport- 
ing  the  fame. 

Now,  whoever  will  reflect  calmly  On  what  has 
been  fubmitted  on  the  animal  and  vital  functions, 
may  eafily  conceive  from  the  fubduction  of  flimulus, 
that  in  every  cafe  of  compreffion  of  any  duration, 
debility  muft  be  the  refult. 

In  this  way  I  prefume  the  difeafe  proves  fatal. 

In  all  inftances  of  inanition,  exifting  at  the  time 
of  extravafation  or  congeflion,  in  confequence  of 
concuffion,  I  fay,  bleeding  is  an  ambiguous  remedy, 
becaufe  the  indication  is  to  take  off  compreffion  by 
the  removal  of  extra vafated  or  infarcted  matter :  this 
can  only  be  effected  by  abforption  and  a  reftoration 
of  energy  to  the  infarcted  vefTels. 

A  queftion  here  arifes,  Is  venefection  adequate  to, 
or  compatible  with  the  indication  ? 

This  is  a  fubject  equal  to  an  Inaugural  Eflay,  and 
improper  to  be  difcufled  at  prefent^  I  mail  only  re- 

jr.ark,  that  ;n  my  opinion  it  is. 

The 


(    3«    ) 

The  fuccefs  of  Bromfield's  practice  appears  to  be 
the  refult  not  of  judicious  prefcriptions,  but  a  leffer 
degree  of  improper  practice. 

We  adduce,  from  their  own  experience,  the  moft 
invincible  evidence  of  the  non-exiftence  of  debility, 
as  the  proximate  caufe, 

All  the  champions  for  this  favourite  hypothecs 
fpeak  favourably  of  the  ufe  of  cathartics,  as  affording 
lingular  relief. 

It  is  almoft  unnecerTary  to  remark,  that  the  energy 
of  the  brain  depends  upon  a  certain  ftate  of  tenfion 
in  the  veffels  of  the  fame,  as  is  obvious  from  deple- 
tion producing  fyncope :  examples  of  which  we  have 
in  the  removal  of  a  ligature  from  the  arm  in  venefec- 
tion,  paracentifis  thoracis  et  abdominis,  and  parturition. 

The  indication  of  cure,  (agreeable  to  Bell  and 
others)  is  to  invigorate  the  fyji em. 

Who  can  reflect:  on  fuch  lingular  inconfirtency 
without  difguft ! 

What  are  the  effects  of  cathartics?  To  debilitate. 

How  far  they  are  calculated  to  fulfil  the  indica* 
tion  needs  no  comment. 

I  prefume  we  are  now  in  poneflion  of  an  incon- 
trovertible fact,  to  fubvert  the  ftately  edifice  of  bril- 
liant and  fertile  imaginations. 

Dees 


(     39     ) 

Does  not  the  invariable  and  fuccefsful  practice 
of  purging  in  phrenitis,  Jynocha,  and  all  other 
Jihenic  difeafes,  and  the  general  averfion  of  Phyfi- 
cians  to  their  exhibition  in  the  afthenic,  fpeak  a 
plain  language;  to  wit,  that  their  falutary  effects 
in  concuflion  can  never  be  reconciled  to  debility 
as  a  caufe,  and,  therefore,  is  one  of  many  in  proof 
of  the  non-exiftence  of  the  fame  ? 

From  the  preceding  reflections  on  the  proximate 
caufe,  it  mufl  be  obvious,  that  the  theory  of  the 
fame  is  the  following. 

When  the  brain  is  fubjected  to  violent  commo- 
tion, the  fyftem  is  greatly  excited;  this  terminates 
in  a  ftate  of  collapfe  analogous  to  fyncope  from 
joy,  and  generally  is  of  mort  duration ;  for  the  per- 
fon  in  a  few  moments  recovers  his  ufual  excitement : 
Butfometimes  the  vital  functions  only  recover  their 
action,  and  the  animal  continue  in  a  ftate  of  fufpen- 
fion.  In  this  ftate  of  the  difeafc,  I  prcfume  indirect 
debility  to  have  no  agency  in  producing  the  pheno- 
mena, and  that  the  difeafe  is  fupported  by  comprcf- 
fion :  Again,  that  direct  debility  arifcs  from  the  fub- 
duction  of  ftimulus,  and  in  this  way  the  difeafe 
proves  fatal. 


METHOD 


I  40  ) 

METHOD  .*/  CURE, 


"WE  may  amufe  our  fancy,  and  indulge  our  in- 
genuity  in  vifionary  fpeculations  on  the  theory  of 
difeafes-y  but,  the  interpofition  of  art.'m  adminifter- 
ing  relief,  is  of  too  ferious  a.  nature  for  fuch  ex- 
ercife. 

As  I  have  dared  to  relinquish  the  beaten  path, 
and  propofe  a  change  in  practice,  it  may  be  confi- 
dered  neceftary  that  I  mould,  in  conformity  to  cuf- 
tom,  mew  the  fallacy  and  inefficacy  of  Xh&fyjiems  of 
our  predeceilbrs  and  cotemporaries  on  this  fubjecT:. 

The  limited  nature  of  this  eflay  renders  fuch  an 
undertaking  impracticable:  I  prefume,  however, 
that  the  arguments  I  ihall  adduce  in  fupport  of  my 
own,  will  fufficiently  evince  the  impropriety  of  thole 
which  have  preceded. 

The  obfervations  which  Ihave  previously  fubmit- 
ted  on  the  fubjedte  of  concuffion  and  compreflion, 
leave  no  doubt  as  to  the  nature  of  the  proximate 
caufe;  and  therefore,  the  indication  refulting  there- 
from is  obvious;  but  to  effedt  the  fame  is  ambigu- 
ous and  difficult. 

The  indication  is  to  take  oif  comprefiion. 

As 


(     4i      ) 

As  comprefiion  in  this  inftance  is  produced  and 
fupported  by  congeftion  in  the  vefTels  of  the  brain, 
or  extravafation,  we  can  only  remove  the  immediate 
caufe  by  abforption,  or  a  reftoration  of  energy  to 
the  vefTels. 

It  would  be  of  advantage  if  we  were  in  pofTeffion 
of  circumftances  to  enable  us  to  diftinguiih  fuch 
cafes  as  are  occasioned  by  extravafation,  from  thofe 
depending  on  congefiion  in  the  vefTels  ;  but  as  this  is 
impofTible,  and  as  three  fourths  of  the  whole  depend 
on  extravafation,  we  mull  choofe  the  leafr.  of  two 
evils — abforption  therefore  is  what  we  have  in  view. 

As  I  have  confined  my  inquiries  to  that  variety 
of  comprefTion  which  arifes  from  concuflion  or  com- 
motion, no  indication  can  prefent  with  refpecl  to  the 
operation  of  the  trepan* 

F  The 

*  We  are  directed  by  Bell,  in  his  Syftem  of  Surgery,  in  all  cafes  of 
comprbsskd  brain,  though  we  are  in  pofleflion  of  rro  circumftances 
to  direct  to  the  feat  of  the  injury,  to  trypan  every  accellible  part  of  the 

CRANIUM. 

If  ever  a  ihirft  for  novelty  led  a  man  into  a  labyrinth  of  folly,  we  have 
an  inftance  of  it  here.  Would  not  a  Phyfician  be  impeached  with  infj.- 
nity,  or  charged  with  fporting  with  the  life  of  his  patient,  who,  in  cafes  of 
apoplexy,  ftiould  direct  the  ufe  of  the  tr  ipan  ?  and  is  not  the  prox- 
imate caufe  of  apoplexy  the  fame  as  that  of  comprefiion  from  concuf- 
fion  >  If  fo,  hive  we  any  one  fact,  which  in  comprefiion  can  require  or 
juftify  an  operation,  more  than  in  apopi. txv  ?  If  the  operation  of  the 
trepan  wa«  unattended  with  |uin,  and  of  fuch  a  nature  that  w<:  nerd 
apprehend  no  danger  from  it»  ufe,  I  fay,  under  fudi  citcunillaiiccs,  if  the 
probiLlity  0  .     ,  ,iiiurciJion  MM  nut  iujIC  than  one  of 


(     42      ) 

The  remedy  in  which  I  repofe  the  greatest  con- 
fidence,  to  effect  the  indication,  is  venefetlion. 

c  Could  I  reconcile  the  idea,  that  depleting  the  fan- 
guiferous  fyfiem  will  increafe  and  invigorate  the  action 
of  the  abforbent^  I  Ihould  with  eafe  furmount  every 
difficulty  as  to  the  propriety  of  the  remedy :  But, 
as  I  am  not  in  poiTeffion  of  fads  for  its  fupport, 
and  as  I  have  no  defire  to  impofe,  by  fubtilty  of 
reafoning,  on  the  minds  of  men,  at  the  expence 
of  my  patients,  I  mull  relinquifh  the  idea,  as  wild, 
vifionary  and  abfurd ;  although  adopting  it  would 
greatly  aid  to  enforce  the  fyftem  of  practice  which 
I  wilh  to  eftablifh. 

It  may  be  aiked,  what  are  the  circumftances  of 
thisdifeafe,  which  indicate  the  ufe  of  the  lancet? 

To  this  I  reply,  that  venefetlion  is  practifed  on  a 
principle  different  from  what  it  is  in  inftances  of 
-phlegmafia  •,  in  the  latter  we  have  in  view  the  pro- 
duction of  debility,  while  in  the  former,  my  object 
is  to  deplete  until  the  fymptoms  of  compreflion 
vanifh  without  inducing  debility. 

Whether 


a  thoufand,  the  operation  would  be  warranted  :  But,  as  the  operation  Is 
tedious  and  laborious  to  the  Surgeon,  and  painful  and  dangerous  to  the 
patient,  it  is  injudicious,  wicked  and  cruel,  and  will  be  avoided  by  all 
wife,  prudent  and  honeft  Practitioners. 


(     43     ) 

Whether  the  patient  is  of  fhlethdrh  habit  or  not, 
blood  fhould  be  drawn  at  certain  intervals,  until 
fymptoms  of  relief  appear,  or  death  enfues-,  for 
the  extravafation  can  only  be  removed  by  abforption  •, 
and  as  this  is  a  tedious  operation,  the  patient  may 
die  from  the  fubduction  of  ftimulus.*  Further,  as 
the  vital  is  in  fome  meafure  under  the  influence  of 
the  animal  funoiions,  and  thefe  are  in  a  ftate  of  fuf- 
penfion,  venefeflion,  independent  of  relieving  the 
patient  from  the  danger  of  fubduction  of  ftimulus, 
by  the  fame  operations,  is  calculated  to  promote  ab- 
forption. 

In  performing  this  operation,  the  following  cir- 
cumftances  mould  be  ftrictly  obferved : — The  blood 
mould  flow  from  a  fmall  orifice,  fo  that  the  ftream 
may  not  exceed  the  diameter  of  a  hair :  this  mould 
be  interrupted  on  the  difcharge  of  an  ounce,  by 
clofing  the  orifice,  and  repeated  every  ten  minutes 
until  one  of  the  effects  I  have  mentioned  appear, 

The  fituation  of  the  patient  fhould  be  horizontal, 
becaufe  this  will  counteract  the  tendency  to  a  ddi- 
quium  animi. 

During  the  intervals  of  bleeding,  the  energy  of 
the  fyftcm  fhould  be  fupported  by  the  diffufible  fti- 

muli  •, 

*   Browne'i  Elementi  of  McJicine, 


(     44     ) 

muii  j  the  exhibition  of  which  muft  be  directed  by 
the  judgment  of  the  Practitioner.* 

I  am  fenfible  of  the  inconveniences  which  will 
refult  from  any  increafe  of  debility,  and  I  have  ac- 
cordingly directed  the  evacuation  to  be  made  in  a 
manner,  which,  I  conceive,  will  effect:  the  removal 
of  phlethora',  without  the  acceflion  of  debility  in 
proportion  to  the  quantity  loft :  For  two  pounds  dis- 
charged in  the  way  I  have  prefcribed,  will  not  be 
equal  to  three  ounces  from  a  large  orifice,  without 
interruption,  and  favoured  by  an  erect  pofture. 

I  truly  lament  the  neceffity  of  an  ambiguous  re- 
medy, but  as  We  are  in  pofleffion  of  none  fo  proba- 
bly judicious,  the  difficulties  attending  its  ufe  mufi; 
be  difpenfed  with :  The  objections,  though  fpecious, 
will  in  a  great  degree  yield  to  a  Scrupulous  exami- 
nation. 

I  have  obferved,  that  the  vital  are  in  fome  degree 
influenced  by  the  animal  functions :  Now,  as  the  lat- 
ter are  in  a  ftate  of  fufpenfion,  the  abforbents  will 
be  diminifhed  in  proportion  to  their  dependence  on 
the  fame. 

Again, 

*  Thefe  will  counteract  the  enervating  tendency  of  venefedrion,  and 
thus  preferve,  under  the  evacuation,  the  rigour  of  the  fyftem. 


(     45     ) 

Again,  as  .the  cavity  of  the  cranium  is  always  the 
fame,  and  the  bulk  of  the  brain  in  proportion  to  the 
ftate  of  its  veffels,  I  fay,  it  is  obvious  from  thefe 
considerations,  that,  as  the  extravafation  neceflary 
to  effect  compreflion  is  very  inconfiderable,*  vene- 
feclion,  by  contracting  the  fenforium,  will  take  off 
compreflion  •,  confequently,  fo  far  as  the  energy  of 
the  abforbents  was  impaired  by  this  caufe,  it  will  be 
renewed  •,  and  the  recovered  (uCpznded  fun  ff ions  will 
afford  feveral  fources  of  ftimulus;  therefore,  the 
evacuation,  fo  far  from  enervating,  invigorates  the 
fyftem. 

The  ftate  of  the  intejlines  fhould  be  early  attended 
to-,  for  by  difcharging  the  contents  of  thefe,  the 
phlethora  of  the  head  will  be  relieved  by  deriving  to 
the  inferior  parts :  This  intention  will  be  bell  effect- 
ed by  ftimulating  cathartics,  thebeft  of  which  is  the 
mercurius  dulcis ;  for  it  not  only  is  attended  with  this 
laft  effect,  but,  by  zftimulus  given  to  the  abforbents 
of  the  intejlines,  communicated  by  confent  to  the 

remainder 


•  I  wai  prefent  at  an  operation  of  the  trepan,  performed  by  thatju- 
diciom  Phjfician  I>oc"i;r  William  Moore,  of  this  city  :  inthi*  inftance, 
the  patient  laboured  under  a  complete  compreffion  of  the  brain,  and  the 
eitravafitei!  matter  Hid  not  exceed  five  graim ;  on  the  removal  of  which  he 
inftantij  recovered  hi.fcufe.. 


(     46     ) 

remainder  of  the  fame  fyftem  of  vefTels,  promotes 
abforption,* 

When  the  animal  functions  are  in  fome  meafure 
reftored,  all  further  evacuation  mould  be  prohibited, 
and  the  cure  fubmitted  to  mercury :  But  as  a  reco- 
very of  phlethora  previous  to  the  removal  of  extra- 
vafated  matter  would  occafion  a  return  of  the  difeafe, 
this  mould  be  avoided  by  due  attention  in  preferving 
a  favourable  balance  between  the  ingefia  and  excreta. 

The  fecondary  fymptoms  fo  frequently  occurring 
and  generally  fatal,  are  attributed  to  a  variety  of 
eaufes.  Mr.  Bell  has  fuggefted,  that  matter  extrava- 
fated  or  effufed  between  the  cranium  and  pericranium^ 
by  ftagnating  becomes  acrid,  ftimulates  and  increafes 
the  action  of  the  veffels,  and  thus  produces  inflam- 
mation, which,  by  the  communication  of  veffels, 
fpreads  to  the  brain,  and  in  this  way  proves  fatal :  I 
conceive  that  the  fame  extravafation,  efFufion,  ftag- 
nation  and  inflammation,  may  equally,  and  fre- 
quently does  take  place  in  the  cavity  of  the  craniumy 
and  is  attended  with  all  the  inconveniencies  men- 
tioned of  the  former.     From  this  confideration,  I 

recommend 


#  On  this  principle  I  explain  the  effects  of  cathartics  in  the  cure 
jf  dropsiis,  2nd  not  by  the  evacuation  giving  occafion  to  abforption. 


C     47     ) 

recommend  the  continuance  of  mercury  for  a  con- 
siderable time,  even  when  all  fymptoms  of  the  difeafe 
have  entirely  difappeared ;  and  if  this  be  ftriclly  en- 
joined, that  train  of  fymptoms  fo  much  feared, 
often  occurring,  and  in  nineteen  cafes  of  twenty  ter- 
minating in  death,  will  be  avoided. 


FINIS. 


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